A Day On the Hill: Meaningful Use, Medicaid, Medicare and More

There is a long list of time-sensitive issues facing primary care -- meaningful use, impending Medicaid cuts, the Medicare sustainable growth rate (SGR) formula, and funding for graduate medical education, just to name a few -- and on Nov. 20, AAFP officers had a chance to discuss all of these concerns (and more) with legislators, congressional staff and representatives from federal agencies.

Here's an overview of the whirlwind day I spent on Capitol Hill with AAFP President Robert Wergin, M.D.; Board Chair Reid Blackwelder, M.D.; and Academy staff.

ONC

In a meeting with Karen DeSalvo, M.D., M.P.H., the National Coordinator for Health Information Technology, and other senior leaders at the Office of the National Coordinator (ONC), we addressed the fact that the cost of complying with the meaningful use program presents a huge challenge for many family physicians. Specifically, we laid out three of the biggest obstacles family physicians face:

complying with meaningful use stage two and the almost impossible task presented by stage three;

the anticompetitive behavior of certain electronic health records vendors, who have established so-called "vendor lock" in many communities around the nation; and

the overall lack of accountability among vendors marketing these products.

The last point is a particularly critical element of our advocacy efforts. Barring a hardship exception, physicians who have not yet attested to meaningful use will see a 1 percent Medicare payment reduction beginning Jan. 1. Those penalties can climb to as much as 5 percent over time.

It's a problem the AMA House of Delegates tackled during its interim meeting earlier this month, when the AAFP delegation backed a resolution directing the AMA to urge CMS to halt penalties related to meaningful use. This same point was emphasized during our meeting with ONC representatives. Why do physicians face penalties for noncompliance, but vendors are not held financially accountable for the performance of their products or their service?

SGRDuring our time on the Hill, AAFP officers and staff met with legislators and congressional staff from both chambers and both parties. In these meetings, we discussed a variety of topics, including the importance of repealing the SGR and replacing it with value-based payment, preventing cuts in Medicaid, and renewing funding for teaching health centers.

Physicians face a 21 percent cut in Medicare payment beginning April 1 unless Congress intervenes. Legislators have patched the SGR issue 17 times during the past 12 years at a cost of more than $169 billion. Bicameral, bipartisan legislation introduced earlier this year would repeal the SGR and replace it with new methods of value-based payment, but to date, Congress has not passed the bill, in part because legislators have not agreed on how to offset the cost of the fix.

Overall, the mood among lawmakers and staff was that enacting a permanent SGR fix would be challenging during the lame-duck session but that Congress could summon the will to enact the repeal-and-replace legislation by the end of March 2015. You can help by telling your legislators to support the bipartisan legislation.

Medicaid CutsFor primary care physicians, cuts to Medicaid payments are even more imminent. Section 1202 of the Patient Protection and Affordable Care Act (ACA) required state Medicaid programs to raise payments for certain primary care services to Medicare levels in 2013 and 2014, but barring an extension, states will be free to drop Medicaid payments back to 2012 levels on Jan. 1.

We emphasized that these cuts -- which vary by state but average more than 40 percent -- represent a severe disruption to the business of practicing medicine and pose a threat to patients' access to care. In fact, total health care spending for Medicaid patients could increase if they can't access their family physician and instead turn to emergency departments.

The Academy supports a bill that would require Medicaid programs to extend the parity payments for primary care for two years. This would not only bolster primary care practices and ensure access to care, it would give us more time to show how important it is for patients to have a regular source of comprehensive care. There is long-term value in providing preventive care, and health care costs can be reduced when chronic conditions are controlled.

Here's another opportunity for you to help. Voice your support for preventing cuts to Medicaid by contacting your legislators through the Academy's Speak Out tool.

Additionally, the Health Resources and Services Administration (HRSA) announced this month that awards for teaching health centers will be reduced from $150,000 to $70,000 per resident for the 2015-2016 academic year. The Academy wrote to HRSA officials about this issue last week, and we drove the point home again in our meetings with congressional staff and legislators.

Residents who train in these programs are more likely to practice in underserved or rural areas when they complete their training. Not only does the funding need to be continued beyond its scheduled expiration on Sept. 30, it should be expanded.

Other Agency MeetingsWe also met with family physician and AAFP member Joe Selby, M.D., executive director of the Patient Centered Outcomes Research Institute (PCORI). PCORI requested the meeting, during which we discussed our practice-based research networks and the work of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

Finally, in a meeting with Rajiv Jain, M.D., assistant deputy undersecretary of health for patient care services at the Department of Veterans Affairs (VA), Wergin discussed our members' ability and willingness to help care for veterans and the need to break down barriers to doing so. Wergin also expressed concern that some family physician practices may struggle to serve veterans if the VA does not pay at least Medicare-level rates.

This issue was debated in depth during the recent AMA
Interim Meeting in Dallas. This was an important discussion because there is
disagreement within the AMA about what constitutes primary care. In fact, many
of our subspecialist colleagues claim that they provide primary care -- and
therefore should qualify for parity payments -- because of their involvement in
the management of certain diseases such as Parkinson's, diabetes and
cancer.

Jerry Abraham, M.D., M.P.H., of Los Angeles, and Joanna Bisgrove, M.D., of Fitchburg, Wis., represent the AAFP at the AMA Interim Meeting. Abraham, a first-year resident at the University of Southern California, was elected an alternate delegate to the AMA's Resident Fellow Section. Bisgrove is the AAFP delegate to the AMA Young Physicians Section.

The globally accepted meaning of primary care, however,
comes from Barbara Starfield, M.D., M.P.H., who defined it as "first
contact, continuous, comprehensive, and coordinated care provided to
populations undifferentiated by gender, disease, or organ system." From
the AAFP perspective, only family medicine, general pediatrics and general
internal medicine are the specialties that train physicians to deliver true
primary care. Other specialty physicians might from time to time deliver
certain services described as primary care, but they are not trained to deliver
comprehensive primary care.

Although some subspecialty groups at
the meeting attempted to change AMA policy regarding who should get Medicaid parity
payments -- if they, in fact, continue -- the Academy's delegation was able to prevent
action by the AMA House of Delegates that would have expanded the Medicaid parity
payments well beyond their initial focus on primary care physicians only. This
means that the AMA's support for proposed legislation that would extend parity payments for two more years will continue.

Next to repeal of the sustainable growth rate (SGR) formula,
this is the most crucial piece of health care legislation the AAFP is focused on
for passage during the lame-duck session. The continued cohesive voice of
organized medicine on this issue represents an important success.

In addition to Medicaid parity, the AAFP's delegation also testified
on other important issues, such as the significant threat to our patients and
our members from the increasingly troubling network narrowing that we see impacting practices in more and more states. The AMA recognized
that this is a significant challenge, and resolutions were moved forward to
address this directly.

It's worth noting that the AAFP, the AMA and more than 100
other organizations recently sent a letter to the National Association of Insurance Commissioners voicing support for
model legislation that would serve as a template for revising state provider network
adequacy standards.

With strong AAFP support, AMA delegates also passed a
resolution asking CMS to halt penalties related to meaningful use (free registration required) and look for ways to continue to incentivize use of electronic health records.

In addition, recognition of the changing landscape in terms
of telemedicine was also a focus during the meeting. Related resolutions moving
forward are consistent with ones we have acted on in the AAFP's Congress of
Delegates.

The AAFP has one of the larger specialty society delegations
to the AMA. Moreover, many of the 115,900 Academy members our delegation
represents are themselves AMA members. These are dedicated family physicians
who advocate for their patients and their communities through involvement with
their state medical societies. Having more family physicians from different
backgrounds at the AMA creates exciting opportunities for us as we continue to
try to find a way to move the house of medicine in a coordinated fashion to
recognize and value family medicine and primary care.

Over the years, our delegation has gained a stronger
presence within the AMA as we continue to work to inform our discussions and
share AMA policies. This is helped by the fact that there are five AAFP members
who are on the AMA Board of Trustees:

Past Chair David Barbe, M.D., M.H.A., of
Mountain Grove, Mo.;

Chair-elect Stephen Permut, M.D., J.D., of
Wilmington, Del.;

Gerry Harmon, M.D., of Pawleys Island, S.C.;

William Kobler, M.D., of Rockford, Ill.; and

Albert Osbahr III, M.D., of Hickory, N.C.

The Academy greatly values the relationship we have
developed with these leaders of the AMA, and we look forward to more
opportunities to work together. Your delegation is quite well respected within
the house of medicine and is led by Joseph Zebley, M.D., of Baltimore, and
co-chair Daniel Heinemann, M.D., of Sioux Falls, S.D.

Recently, we have been blessed by an influx of dynamic
family physicians who are early in their careers. This year, our delegation
included Uniformed Services chapter member Janet West, M.D., of Pensacola, Fla.;
Aaron George, D.O., a third-year
resident at the Duke Family Medicine Residency in Durham, N.C., and Ajoy
Kumar, M.D., of St. Petersburg, Fla. In fact, we had many people from other
delegations praise our organization for being able to bring younger voices to
the table.

An impressive accomplishment for our delegation during this
meeting was that Jerry Abraham, M.D., M.P.H., of Los Angeles, one of our
resident members, was elected as an alternate delegate to the AMA's Resident
Fellow Section. A first-year resident at the University of Southern California,
Abraham will be sitting in the House of Delegates this summer during the AMA's Annual
Meeting. This speaks well to his leadership skills not only within the AAFP but
also the AMA.

The Academy continues to work for our members and our patients
in every venue we can. The AMA meeting is certainly a different body and
culture from our AAFP Congress of Delegates; however, the issues discussed at
AMA directly impact our patients, our communities and our members. Thanks to
all of the family physicians who are involved in the AMA. This is another
important avenue for advocacy, and we appreciate your efforts. As they say at
the AMA, together we are stronger!

California AFP's Success Shows What Chapters, FPs Can Accomplish at State Level

It's that time of year again. For the past 15 years, by the end of October, I would start counting the wins and losses of my favorite college football teams in preparation for the Bowl Championship Series that crowns a national champion. However, with the introduction of a long overdue college football playoff this season, polls and computer rankings are no longer quite as compelling. Although I've been enjoying some great football games, I've been tracking and counting something even more interesting instead.

Like many of you in your own states, I also advocate on health care issues in my home state of California. As the legislative session comes to an end for the California State Assembly, the California AFP's record is pretty impressive. Of the CAFP's 19 priority bills, Gov. Brown signed 17 of them this year. Among the victories for CAFP were budgetary expansions for primary care workforce training and the elimination of a retroactive 10 percent reduction in California Medicaid (Medi-Cal) provider payment to the tune of more than $42.1 million.

Other Medi-Cal related wins include the creation of an oversight body for children's health, streamlining enrollment, and expansion of enrollment eligibility categories. New laws will also require Medi-Cal managed care plans to provide interpretation and translation services to their participants. Several new pieces of legislation will strengthen team-based care by allowing physician assistants to certify claims for disability, authorizing medical assistants to handout labeled and prepackaged medications after consulting with appropriate health care professionals, and requiring schools to provide emergency epinephrine auto-injectors.

On the workforce front, in addition to increased funding for primary care training, new legislation has cleared the way for graduates of accelerated and fully accredited medical education programs to become licensed physicians in California.

Hard work by CAFP staff and members culminated in the passage of a resolution regarding patient-center medical home (PCMH) definition. For the past six years, this piece of legislation was kicked about by some as leverage for their own political ambitions. In previous sessions, it had been snatched from the jaws of victory by last-minute legislative maneuvering and was dismissed by the governor as an "evolving concept."

Just as with any successful football team, team work made the difference in getting it done this time. CAFP enlisted and energized attendees of its All Member Advocacy Meeting by focusing them on passing priority legislation. We trained an army of family physicians to become expert patient advocates on PCMH issues. In addition, contributions to FP-PAC, California's family medicine political action committee, opened doors for our well-trained grassroots advocates to meet with influential legislators.

Furthermore, 2014 was declared "The Year of the Family Physician" in California when a resolution sponsored by CAFP passed the legislature. The hashtag #2014YearFP was a Hail Mary idea dreamed up by Ron Fong, M.D., M.P.H., at the University of California-Davis Family Medicine Residency Network. During the year, it gained momentum within local communities and city councils and was picked up in social media around the nation and the world.

Although the Year of the Family Physician is drawing to a close, an even broader effort touting the value of family medicine and primary care is just getting started. As we embark on the road to achieve the goals of Family Medicine for America's Health and the Health is Primary campaign, I strongly invite your input and involvement in this vital process as we transform our medical neighborhoods. Keep informed and get involved.

And finally, I would be interested to hear about your state chapter's legislative wins in the comments field below. Tell me about your success stories!

We’re Doing Our Part to Keep SGR Issue on Congress' Radar

I will only be AAFP president for three more weeks, but there's a lot to do in this final month of my term. Throughout the year, I have had opportunities to represent the Academy at meetings with a number of organizations as we discuss important concepts such as team-based care and the patient centered medical home. One such opportunity came just this week when I participated on a panel for a Capitol Hill briefing that addressed payment reform, including the need to repeal the Medicare sustainable growth rate (SGR) formula.

This event was organized by the Society for General Internal Medicine (SGIM), which reissued a 2013 report developed by the National Commission on Physician Payment Reform. Many of the principles and recommendations in the report are in line with what the AAFP has been advocating for several years. Given the urgent need to push for passage of the bipartisan, bicameral legislation on SGR repeal already in play, this was an ideal time for the commission's report to be reissued.

I joined a panel that was moderated by SGIM president William Moran, M.D., and included SGIM health policy chair Mark Schwartz, M.D., and American College of Physicians EVP Steven Weinberger, M.D., also a member of the commission. We used this opportunity to review the principles and recommendations in detail with a room packed with legislative aides from both the House and Senate. Our most important ask was to encourage legislators to pass the SGR repeal proposal before the Congress adjourns in December.

The commission's report, like the Academy's longstanding advocacy position, stressed the need to repeal the SGR, which again poses a looming threat to cut physician Medicare payments by more than 20 percent if Congress doesn't act by March 31.

As part of this briefing process, we reviewed many of the report's recommendations, which are in line with what the Academy has been saying in our own discussions with CMS, legislators and congressional staff for years.

Some of these important recommendations include the need to transition away from the fee-for-service model. We outlined the perverse incentives that this model has given rise to in our health care system. Although fee-for-service will continue to be important for some aspects of payment, we have to fix the disparities in current fee-for-service payment rates because they will be a foundation for future payment models. There have to be opportunities to rebalance fee-for-service payments, to boost undervalued evaluation and management codes, and to recalibrate overvalued codes -- many of which have not been revisited in more than 20 years despite huge gains in efficiency.

Our patients' health is becoming increasingly complex to manage, especially in a Medicare population in which 60 percent of patients have three or more chronic conditions. This additional complexity further accentuates the dramatic disparity between how our fee-for-service model pays for procedural services compared to primary care services. New technology has reduced the time it takes to perform certain procedures, yet payment for these services has not been reduced. This contributes to the erosion of primary care incomes which exacerbates our primary care workforce shortage.

We emphasized the real need to recognize that compared with procedural services, primary care services require face-to-face time that cannot be shortened to increase volume without decreasing patient-centeredness and quality.

Another recommendation specifically addresses the significant potential for cost savings and improved care for patients with chronic conditions. The commission report noted that 5 percent of patients in this country account for 50 percent of our health care spending. This will continue to drive an increasingly disproportionate share of spending as more and more patients develop multiple chronic conditions. This is an area that has significant potential for cost savings as we continue to transform our practices.

As family physicians, we know what to do. Much of the answer lies in the patient-centered medical home, and implementing better and more efficient team-based care. Our country needs a stronger primary care foundation -- the essential message of the Commission’s report. The more incentives we can find for primary care and improving access for all of our patients, the more we will save in terms of downstream costs.

We must move away from “wrong care, wrong place, wrong time” to ensuring patients get the right care, in the right place, at the right time and from the right person.

Overall, attendees of the briefing were interested in the recommendations. We stressed that this push is a unique opportunity that brings together all of organized medicine in support of proposed legislation. In addition, once the 2014 midterm elections are over, the unique political landscape of a lame-duck session could grease the skids for passage of the bill.

Once the 114th Congress convenes in January, the SGR repeal legislation will lapse. In addition, because of retirements and potential election-driven shifts in power, significant changes will occur within the committee leadership in Congress, posing potential roadblocks to restarting the bipartisan process. Therefore, this lame-duck session is a unique and rare opportunity for some congressional lawmakers to put a feather in their hat by moving forward on an important and long-sought-after repeal of this fatally flawed formula.

Walk the Talk: Students, Residents Step Up to Support AAFP Advocacy Efforts

If you want students and residents to get involved in an issue, sometimes all you have to do is ask.

At an AAFP Board of Directors meeting earlier this year, we heard a report on FamMedPAC, the Academy's political action committee, which helps elect candidates to the U.S. Congress who support the AAFP's legislative goals and objectives.

During the National Conference of Family Medicine Residents and Medical Students, we challenged our respective member segments to see who could raise the most money for FamMedPAC, the Academy's political action committee. Residents and students donated more than $1,000 during the three-day event.

The report included data on the relatively small category of student and resident support. As the resident and student members of the Board, we thought that category could -- and should -- be much larger. The perception has been that students and residents don't have a lot of money to contribute and, therefore, typically aren't a focal point for fundraising efforts.

However, we thought our colleagues would step up to the plate if given the opportunity, so we came up with the idea of the FamMedPAC Challenge. During the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., last week, we rallied our respective groups of students and residents to support the PAC. We knew that the residents and students would answer the call and donate, but the results exceeded our expectations.

Advocacy consistently ranks among the top Academy priorities for students and residents, and both groups consistently bring issues to the AAFP's attention because they feel so passionate about the advances that can be made for our specialty and, more importantly, our patients. There were nearly two dozen resolutions in the resident and student congresses at National Conference that related specifically to advocacy.

During the conference, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., gave a presentation on advocacy, and the room was packed. As part of that session, students and residents worked up an advocacy issue, which they then transformed into short "elevator speeches" in small groups. Each group practiced pitching their talking points to the entire room, and we were blown away by how well they articulated their messages.

Throughout National Conference, we spoke about the FamMedPAC Challenge and the PAC from the stage, but we also got the word out through social media and, of course, lots of old-school, face-to-face chatting. Both of us handed out donation forms with $1 (an actual dollar bill from our personal accounts) and a PAC donor ribbon attached. Many students and residents had already donated during the past year, but some gave again by adding $9 to our $1 for a $10 contribution, the minimum amount to get their respective group a point toward winning the challenge. Most donors, however, were new.

The FamMedPAC Challenge was a huge success. We had 51 donations: 31 residents contributed a total of $629, and 20 students gave a total of $431 for a three-day total of $1,060, which is by far the most money ever donated to the PAC during National Conference.

Now we'd like to challenge the rest of the AAFP membership. If medical students and residents -- with their ever-growing student loan burdens -- can reach into their pockets and make a donation to help advance our specialty, won't you?

Teamwork: AAFP, PA Groups Find Common Ground

I recently represented the AAFP at meetings with leaders from the American Academy of Physician Assistants (AAPA) and the Association of Family Medicine Physician Assistants (AFMPA), and I was honored to be an invited guest to the AAPA meeting in Boston a few weeks ago. The leadership of the AAFP and the AAPA have previously attended each other's board meetings to review proposed legislation at state and national levels. This is a critical interaction that allows our organizations to identify areas in which we can work together.

For example, in Boston, I learned about a proposal in Missouri regarding so-called assistant physicians, who are not PAs but medical school graduates who have not completed residency training. Not only does this proposed measure create potential confusion because of the title of these would-be health care providers, it also would create significant challenges in terms of how unlicensed providers should be designated, regulated and utilized.

I recently met with leaders from the American
Academy of Physician Assistants, including (from left) President John
McGinnity, PA-C; President-elect Jeffrey Katz, PA-C; CEO Jenna Dorn; and Board
Chair Lawrence Herman, PA-C.

This issue was directly addressed by the AMA House of Delegates at its annual meeting last month. The AAFP delegation coordinated with our PA colleagues and testified about concerns raised by this issue. A resolution opposing the use of medical school graduates as assistant physicians was adopted with wide support.

Our common interests with the PA groups aren't limited to advocacy. PAs are trained in the medical model of care involving diagnosis and treatment, as are physicians, and they follow rigorous and standardized educational, certification and licensing processes. Last fall, we reached a unique arrangement with the AAPA, which was working to identify activities that would fulfill the performance improvement requirements for its new certification of maintenance program. The AAPA came to us seeking a collaborative agreement through which the AAPA could offer the Academy's four METRIC (Measuring, Evaluating and Translating Research Into Care) performance improvement modules within the AAPA's own learning management system.

METRIC is the AAFP's flagship performance improvement product line and is critical for lifelong learning and maintaining certification. This agreement has been finalized, and PAs may now purchase and access the AAFP's METRIC modules directly from the AAPA, which coordinates marketing and accreditation of the modules. This joint venture represents an important way to share resources and not reinvent educational wheels as we move toward quality improvement in continuing education. Moreover, this relationship reinforces the value that others see in our educational offerings.

This is all worth noting, in part, because 40 percent of AAFP members work with PAs, who assist us in ensuring that we provide effective care and improve our patient outcomes. Team-based care is important to meeting the goals of the quadruple aim -- improving patient outcomes, improving patient and provider satisfaction with the system, and doing so at lower cost.

Family physicians and PAs are working together not only at the practice level but also at the national level, and I look forward to further discussions and collaborations with these groups. Together we are making progress in providing better, more effective care for our patients.

Changing the Conversation: What Would It Take to Make Using Our EHRs Truly Meaningful?

During one of the state chapter meetings I attended
as a member of the AAFP Board of Directors, I asked participants if they were
using electronic health records (EHRs). About 80 percent said they were. Then I
asked the group how many of them were satisfied with their EHRs. Only a few
hands went up. In fact, I heard some angry comments.

Administrative hassles are hindering family
physicians. “Just one more thing,” is a common refrain, with the implication being
that if there is one more thing to report or document -- or anything else that
gets in the way of patient care -- it could be the “one more thing” that prompts
a physician to quit.

ICD-10, the Physician Quality Reporting System,
meaningful use -- how much more will it take before family docs just say no?

It's clear the creators of meaningful use had good
intentions. The concept was intended to help physicians transition to EHRs. The
carrot was financial. The money saved throughout the health care system by using
EHRs could be shared with physicians, thus encouraging them to implement EHRs. (With
the stick, of course, being a financial penalty for not complying.)

The idea was that going electronic would:

improve
patient care,

decrease
medical errors,

improve
office efficiency and

avoid
redundancy in ordering tests.

Having healthier patients, fewer medical errors,
less testing and improved efficiency would net an obvious health care savings.
In fact, researchers predicted in 2005 that health information technology would
save the country more than $80 billion a year. Yet U.S. health care
expenditures have continued to skyrocket due to many factors, including the
health IT shortcomings.

So, did we go wrong somewhere?

Interoperability has been, and remains, a major
stumbling block despite the Academy's hard work on the issue for more than a
decade. Back in 2003, there was a lack of awareness among policymakers and EHR
vendors that interoperability was even an issue. So, the AAFP worked with
legislators, federal agencies and vendors to get it on their radar.

The AAFP knew standards were needed, so next, the
Academy collaborated with other stakeholders to help create the ASTM
Continuity of Care Record
(CCR), a patient health summary that can be created, read and interpreted by
EHRs developed by different software companies. That standard has become part
of meaningful use.

Family physicians have led the way and been early adapters of electronic records, but the technology still falls
short of what we want and need in terms of useability and interoperability.

As AAFP President-elect Robert Wergin, M.D., of
Milford, Neb., recently pointed out in his blog on the topic, when a patient leaves a primary care practice for a subspecialist consultation,
the respective EHRs at the primary care practice and the subspecialist’s
practice aren’t necessarily able to communicate. This is a barrier to care
coordination, and the Academy continues to work with the Office of the National
Coordinator (ONC) for Health Information Technology on this issue.

This critical shortcoming is why the Academy was an
early contributor and founding member of the direct exchange project, which allows physicians to send secure, confidential emails to other physicians.

Unfortunately, EHR
developers have little incentive to change. The ONC recently issued a proposed
rule for 2015 that included voluntary updates related to certification
criteria, interoperability and regulatory improvements. In a letter to the ONC, the AAFP said that voluntary guidelines would
create confusion about what is and isn't required, adding undue complexity to an
already complex program. The Academy urged the agency to urge work with
stakeholders to create better means than a voluntary certification program.

It seems unlikely that
EHR developers are going to fix the issue of interoperability on a volunteer
basis. But just think how much more “meaningful” my use of an EHR would be if it
could communicate with the EHR of the radiologist or cardiologist across town.

Add to that the fact that many EHRs aren’t
user-friendly at all. Documentation and reporting has become cumbersome, and being
conscientious about keeping thorough electronic patient records results in less
time for patient encounters. In fact, there have been indications that EHRs that
satisfy meaningful use and appropriate coding protocols can:

The main thing that electronic records have
accomplished is improved billing. But surely this isn't all we want to see come
from this investment. We are seeking a system that would improve patient satisfaction
and improve patient outcomes. The electronic record is a natural for following patients
with chronic disease and surveying your patient population for health concerns.

While tracking specific metrics such as a hemoglobin
A1c has improved with use of electronic records, tracking actual improvements
in health has not worked so well. What would it take to make this happen?

It is estimated that one-third of health care expenditures
overall can be attributed to unnecessary administrative burden. Of that, the time spent
doing administrative work and documentation during a patient encounter has been
estimated to be as high as 60 percent.

There is a section in the Patient Protection and Affordable
Care Act -- Section 1104 -- that seeks to improve these hassles. This "administrative
simplification" section was passed by Congress even before meaningful use
reporting began. However, the same rules should apply. The
section includes operating rules for HIPAA transactions, utilizing a unique
identifier and setting up certain rules that would simplify reporting for
health plans.

Wouldn't it be great to see a patient and not have
to worry about how many bullets are included in the current history of illness?
Instead, you could just look at the past medical history as it applies to the
patient, review only symptoms that are specific to the patient's problem and pursue
only clinical decision-making specific to patient care needs. Charting this way
would involve minimal amount of physician time, and patient care documentation
would be the purpose. The dual worries of coding and reporting would go away.

My practice is sending one of our physicians to
an out-of-town course to become an EHR "superuser" so he can help the
rest of us become more efficient in using our system. It seems odd that after
years of medical training we need even more training to become IT experts.

Through our state chapter visits and other channels,
the members of the AAFP Board of Directors have heard members' concerns --
believe me! We will continue working to ease administrative burdens. We are
looking at ways to decrease the number of codes and the complexity of coding.
In the meantime, we can all continue to educate ourselves so we can make best use
of the current system.

How Family Medicine Upstaged Ben Affleck

It's
not an everyday occurrence when a family physician proves to be a bigger draw
-- at least for a few minutes -- than a two-time Academy Award winner. But that
was the case last Wednesday when Sen. John McCain, R-Ariz., stepped out of a Senate
Foreign Relations Committee hearing (where Ben Affleck was testifying about issues in
the Congo) to talk with me about the sustainable growth rate (SGR) formula and
the need to extend funding for teaching health centers.

The AAFP Board of Directors was meeting in Washington, but we made time in the agenda to talk to our own legislators about these critical issues. I had met with McCain's staff several times in previous trips to our nation's capital, but this was my first visit with my state's long-time senator. The meeting was quite encouraging. In fact, McCain was one of nearly two dozen members of Congress who agreed to co-sponsor the SGR Repeal and Medicare
Provider Payment Modernization Act last week.

The
bipartisan legislation introduced last month in the House and Senate would
permanently repeal the SGR and enact reform that would support improvements in
health care delivery. If Congress doesn't act before March 31, the SGR would cause
Medicare payments to physicians to be cut by 24 percent.

It's
easy for individuals to think they can't make a difference against huge
challenges like this one, but the reality is that legislators might not even be
aware of a problem unless a constituent is willing to bring it their
attention. That was the case with the issue of teaching health centers -- or
the lack of them -- in Arizona.

Fewer than half of the states have teaching health centers, and Arizona is one of
those on the outside looking in. Sen. McCain wasn't aware of that shortcoming.
But when I told him about the benefits of teaching health centers and why funding
should be extended beyond 2015, he wanted to know more. I will certainly follow up with his staff to make sure he
understands the value and importance of teaching health centers.

Arizona,
a state with 6.5 million people, has only eight family medicine residencies, including
the University of Arizona Family Medicine Residency Program where I am an
associate professor. Adding a teaching health center would be a huge step in
the right direction, ensuring family
medicine becomes a more vigorous force in health care delivery.

Sometimes
we find support in seemingly unlikely places, but we have to be willing to look
for it. Have you reached out to your federal legislators about the SGR and graduate
medical education?

Primary Care Education at Forefront of Obama Budget Proposal

Washington, D.C.,
is always an exciting place to be, but it especially was for me this week
because the AAFP Board of Directors is meeting here to advocate for our members
and improved health care for all Americans. But today was an even better day
than I expected. As we gathered this morning before our meeting, we were
encouraged by some good news in USA Today.

For months, the
AAFP has been working with the White House and the Health Resources and
Services Administration (HRSA) to address the need for increased funding in graduate
medical education (GME). Today, information provided by the White House Office
of Management and Budget reveals that there will be some good news for primary
care Tuesday when President Obama releases his 2015 budget.

Specifically, the
document released by the Office of Management and Budget to USA Today
(and later shared with the Academy) says the Administration plans to budget an
additional $5.23 billion during the next 10 years to train 13,000 more residents in
primary care "and other physicians in high-need specialties." The
document does not specify what those high-need specialties are, but last
year the Council on Graduate Medical Education (COGME) called for increases in GME funding in "high priority specialties," including family
medicine, geriatrics, general internal medicine, general surgery, high priority
pediatric subspecialties and psychiatry.

The AAFP has long
advocated that our country put more resources into graduating more medical
students into primary care to meet the workforce needs of our country as our
population continues to grow, as it continues to age, and as more patients get health
insurance because of health care reform. This proposed budget speaks directly
to this need.

Additional residency positions in primary
care also are needed to keep pace with the opening of new
medical schools and expanding medical school class sizes. COGME recommended
that Congress continue funding existing GME positions and increase funding to
support 3,000 more graduates per year. The President's budget would take a step
in the right direction, providing additional funds through HRSA to train an
additional 1,300 residents per year in high-need areas, including rural areas.
It is critical, however, that any such increase that is implemented must ensure
a majority of these positions be in primary care: family medicine, general
internal medicine and general pediatrics.

Reinforcing this
need, the document says residencies vying for the additional slots would have
to demonstrate that they "train and retain physicians in primary care and
use team-based models of care that enable all providers to work at the full
extent of their abilities, and adopt new models of care, such as the
patient-centered medical home or accountable care organizations."

It is important
that we identify and finance training sites that may be outside the traditional
hospital setting. The budget document says that for the new competitively
awarded residency slots, priority would be given to hospitals and other
community-based health care entities.

National Health Service Corps

One
proven way of getting physicians into primary care is through the National
Health Service Corps (NHSC). During the past several years, we have seen
important growth in this program. The number of physicians serving in the NHSC has more than doubled during the current administration, from 3,600 in 2008 to 8,900 last year. The President's proposed
budget would provide $3.95 billion in mandatory funds, expanding the number of
NHSC health care providers in underserved areas to 15,000 each year from 2015
through 2020.

The AAFP has
strongly supported growth in the NHSC, which offers scholarships and loan
repayment assistance to support qualified family physicians and other health care
professionals who are willing to work in communities across the country that
are designated as health professional shortage areas. The program makes it
easier for students to choose primary care careers without facing
insurmountable debt and helps address critical access issues by placing new
physicians in areas where they are needed most.

Medicaid Payment

The AAFP has been
advocating for the increase of Medicaid payment rates to Medicare levels for more than four years. The proposed
budget would extend increased Medicaid parity payments for primary care
services through 2015 at an estimated cost of $5.44 billion.

We thank the
administration for this proposed increase, and look forward to working with
Congress to extend these increased rates for five years to create a period of
access stability as our members continue to transform their practices to more
effective patient-centered medical homes, and as we transition away from
payment models that pay for volume to models that pay for value.

It's important to
remember that Tuesday's announcement will be regarding a proposed budget. These
specific proposals from the White House directly address the workforce needs of
our country, and would help produce the critically needed primary care
physicians Americans need and deserve. We are eager to continue our
discussions with this administration and Congress to work to achieve these
outcomes.

Much work and
debate will remain before it is finalized, but this proposed budget is an
important step forward as it is a real and meaningful investment in primary
care. It represents recognition of the foundational role that primary care must
play in our transforming health care system. The AAFP stands ready to help
ensure that all Americans get the right care from the right person in the right
place at the right time.

Advocacy Improves Community Health Far Beyond Exam Room

I have been involved in advocacy, in one form or another, since middle school: collecting money for the Jerry Lewis telethon, arranging a speaker for my high school class and working on teen pregnancy issues in residency. The issue that helped me fully understand the nuances of advocacy, however, was the death of a patient who was a victim of domestic violence.

Knowing that I wanted to help to change the health conversation, I asked myself, "Who else in the community has a stake in this issue, and what existing programs might need assistance?" Then I met with the local women's shelters to find out what they needed and how family physicians could connect women who need help from these resources. I also worked with law enforcement officials, educated myself and eventually figured out how to get things done.

Family physicians face a lot of challenges, including payment issues, new regulations, public health issues and more, but we don't always know how to fix the problem or create change in our communities.

As President of the Pennsylvania division of the American Cancer Society, I spoke during an event at the
State Capitol. Our advocacy efforts helped the Clean Indoor Air Act become law in 2008.

It helps to be able to take our frustration with these various issues and turn them into opportunities for change and leadership. Getting involved in advocating on our issues can provide an opportunity to get off the daily routine hamster wheel and develop and use different skills. We are trained in family and community medicine, so engaging in pressing issues can be a great fit for our skills. Addressing and fixing these nagging problems can help us reenergize, improve our professional satisfaction and build our professional network.

Start by asking, "What am I passionate about?" "What issue is hurting my practice or affecting too many of my patients?" The basic process of identifying a problem, gathering stakeholders, setting goals, developing a communications plan and engaging the community can be applied to an array of public health issues. For example, when I was on the board of the Pennsylvania division of the American Cancer Society, a state senator had been working for years -- without success -- on a bill regarding clean indoor air.

This is where those different skills I mentioned kick in. In this effort, I was able to provide testimony in my state legislature and inform the public about the issue by working with the media. By networking, with persistence and professionalism, we were able to bring critical allies -- including the state restaurant association -- into the discussion. The addition of physician partners adds urgency and credibility to an issue. You can be that valued partner.

By pulling other physicians and medical organizations into the effort, we were able to provide powerful stories from patients whose health had been affected by smoking in public places. We were able to gather data related to the high medical costs associated with working in a smoke-filled environment. These two factors personalized the story and proved to policymakers and the public that this was a public health problem that needed to be rectified.

Finally, the Clean Indoor Air Act was signed into law in 2008, prohibiting smoking in public places and workplaces statewide.

For some, advocacy means stepping out of their comfort zone, or at least expanding it. Speaking in front of large groups can be nerve-racking, especially when cameras are rolling. But the results -- healthier communities and personal growth -- can be fantastic.

Our communities -- and our country -- need us, and not just in our practices. Being involved in these types of issues, whether locally or nationally, showcases who we are, what we do and the fact that primary care physicians are leaders in community health.

On April 7-8 in Washington, family physicians will have an opportunity to learn about advocacy at the Family Medicine Congressional Conference. Attendees will learn how to engage legislators and share stories from their practices in a way that can inspire change. I hope to see you there.

Academy is Working to Define, Value Care Management

Editor's note:
During the AAFP's Scientific Assembly in San Diego, a panel discussion on
practice transformation generated far more questions than the panelists could answer in the time
allotted. This is the second post in an occasional series that will attempt to
address the issues members raised -- including the valuation of care management
fees -- during the panel.

The AAFP
has been advocating for years that a designated care management fee should be paid on a per-member,
per-month basis as part of a blended payment model that also includes enhanced
fee-for-service and performance-based incentives.

Family
physicians always have done what is needed to care for our patients. We answer
phone calls and e-mails, review and compile information from subspecialists,
coordinate care transfers in referrals and in the hospital, handle prior
authorizations, and ensure so many more aspects of making sure our patients get
the care they need are covered. Although all these factors are critical for
good patient outcomes, none of them generate payment for family physicians
doing this important work.

The AAFP
is pushing for payers to recognize the value inherent in care management services.
Although we are seeing progress in this area, our efforts are complicated
because of the amount of confusion -- and disagreement -- regarding what care
management services should include and what they are worth. The Academy is
working to define patient care management so that these services can be
understood and valued appropriately.

For
example, the AAFP's Robert Graham Center for Policy Studies in Family Medicine
and Primary Care has conducted a literature review that considered more than
600 studies that offered evaluations of care management fees and reimbursement
in care management and/or care coordination. Sixty-one articles were deemed
relevant for inclusion in the review.

The
range of fees found in that review was striking, with a low of 60 cents per
beneficiary per month in one demonstration to a high of $444 per beneficiary
per month in a congestive heart failure program. Some payers are offering $2 to
$4 per beneficiary per month. Obviously, these low numbers are unacceptable.

Some disagreement
exists as to what dollar amount per beneficiary per month would be most
appropriate to properly value the work required to provide high quality care,
but we are working on a process to help make these critical decisions.

The
Graham Center's work will be used as the basis for a concise document that
defines what the AAFP considers to be the essential elements of care management
fees. That document will be vetted in February during a meeting of the
Academy's Commission on Quality and Practice.

The next
step will be for the health care advisory firm Avalere Health LLC -- which has been working with
the Academy on payment issues since 2012 -- to value the AAFP's definition of a
care management fee. That valuation, the definition and the underlying
literature review then will be used to create a policy document on the valuation
of care management fees. That document is expected to be presented to AAFP
Board of Directors later this year.

When the
work is done, we'll have one seamless document we can take to payers -- both
public and private -- and say, "Here is what we do for our patients. This
is what care management means. It should be valued and paid for, and this is a
reasonable care management fee."

The
document also will be used to help AAFP members evaluate contracts that include
care management fees.

AAFP Takes SGR Message to Capitol Hill

After spending a week at the AMA Interim Meeting in National Harbor, Md., AAFP leaders met with members of Congress and congressional staff Nov. 19-20 in Washington to
discuss the repeal and replacement of the sustainable growth rate (SGR) formula and other issues of importance
to family medicine. AAFP President Reid Blackwelder, M.D., offers an update on
the Academy's advocacy efforts in the video below.

The Good, the Bad and the Ugly … A Tale of Three Bills

Congratulations to our Louisiana, Ohio and
Pennsylvania chapters for winning Leadership in State Government Advocacy Awards
at the AAFP's State Legislative Conference, Nov. 1-2 in Broomfield, Colo. Our
national and state legislative leaders spent that weekend discussing issues related
to scope of practice, the Patient Protection and Affordable Care Act, opioid
abuse and rural workforce. This annual event presented a great forum for
knowledge sharing and cross pollination of legislative strategies across the
states.

If you have spent any time at your state
legislature, you know that actions are worth more than words, and that
legislators -- despite good intentions -- may craft bills that are good, bad or
just plain ugly when it comes to public health and the practice of medicine.

My state legislature is no exception. In California,
we just ended the first of a two-year legislative session, which meant that all
bills were chartered, killed or pushed onto a second year session for more
work. This year, we saw three scope-of-practice expansion bills: one for
pharmacists, one for nurse practitioners and one for optometrists.

Here is the low down on each of these bills.

The
Good

The first in this triad of bills became law, allowing
pharmacists to furnish self-administered hormonal contraceptives, nicotine
replacement products, and prescription medications not requiring a diagnosis
that are recommended for international travelers. In addition, they will be
allowed to order and interpret tests for the purpose of monitoring and managing
the efficacy and toxicity of drug therapies in coordination with the patient's
primary care physician, including by faxing or entering results in patients'
medical records. And finally, they are allowed to initiate and administer
routine vaccinations recommended by the CDC's Advisory Committee on Immunization
Practices.

Why, you ask, is this expansion good for family
physicians? The house of medicine initially opposed the bill. However, after several
thoughtful discussions with pharmacists, the bill was amended to bring
pharmacists into a patient-centered medical home model, which allows them to
become a part of the health care delivery team in their area of expertise. This
will result in more coordination between a patient's primary care physician and
pharmacist, and it will decrease the barriers our patients may face in
obtaining certain treatments.

It is always good when each member of the health care
team is participating to the maximum that their training allows.

The
Bad

In stark contrast to the pharmacists, the nurse
practitioner scope bill exemplified how bills should not be worked through
the legislature. After years of working with physician organizations --
including by supporting several prior bills that were passed to allow increased
scope of practice for nurse practitioners within a collaborative agreement
structure -- nurse practitioners tried to pull a fast one on the legislature
this year. Nurse practitioners argued that they can fill in primary care
shortage gaps where family physicians cannot or are not willing to do so.

However, physician organizations successfully argued
to the legislature that independent nurse practitioners would not improve
quality and may adversely affect patient safety. This argument was further
augmented by data provided by the California AFP showing that independent nurse
practitioners would not improve primary care misdistribution in our state.

To their credit, state legislators heeded our message,
and the bill failed to pass out of committee. By focusing on obtaining
independence, nurse practitioners sought to further fragment the health care delivery
system and to further undermine the cornerstone of health care reform by
putting their financial self-interest above coordinated, patient-centered care.
The nurse practitioner bill simply highlighted deficiencies in our fragmented
health delivery system without providing a workable solution to the primary
care workforce shortage.

The
Ugly

The last of the three scope bills would have allowed
optometrists to diagnose and treat all conditions presenting with ocular
manifestations. It would not only allow them to initiate treatment of chronic
diseases -- such as diabetes and hypertension -- but also complex conditions such
as systemic infections and autoimmune diseases.

Needless to say, the house of medicine was strongly
opposed to this bill. Yet, the author, an optometrist himself, would not take on
any amendments to his bill. He was able to move this bill out of the committee that
he chaired. But facing a high likelihood of defeat on the floor, he pulled the
bill for further work next year.

Lessons
learned

I had an opportunity last week to participate in a
community chronic disease forum hosted by the author of this trio of scope
bills. After some careful repartee sitting around a small table, I came to
realize that he, like many, if not all, legislators, drafts bills with the best
of intentions. In this vein, it would be in our best interest as family
physicians to keep close tabs on all our legislators and develop relationships
with them. Successful advocacy takes good will and influence to bring about
change.

So, what can you do? You can join the thousands of
family physicians who have signed up to become key contacts for advocacy. Key contacts receive regular updates from the Academy's government relations
staff on issues important to family medicine, and they occasionally are asked
to reach out to their legislators by phone or e-mail to tell their stories and
let lawmakers know how issues are affecting family physicians and our patients.

For those who aren't able to get directly involved
with advocating for family medicine, you can still make a difference by
supporting FamMedPAC, the Academy's federal political action committee. FamMedPAC enhances AAFP
advocacy efforts by making direct, nonpartisan contributions to candidates for
the U.S. House of Representatives and the U.S. Senate. FamMedPAC provides AAFP
members with an easy way to get involved in the political process and to
support candidates who support family medicine.

With mid-term elections approaching, you'll be
helping to improve the delivery of health care in this country, and helping put
family physicians on equal footing with the powerful insurance companies and
trial lawyers. It's one way to ensure our voice is heard on Capitol Hill.

The Challenge of Working With Health Plans

Every
year, AAFP leaders and staff members meet with several of the nation's largest
health insurance companies to discuss payment and other issues important to family
medicine. Last week at the Academy's headquarters in Leawood, Kan., we met with
UnitedHealthcare (UHC), and it provided us with an opportunity to express our
concern regarding UHC's recent move to make significant cuts to its Medicare
Advantage provider network just a few weeks before Medicare open enrollment.

UHC
representatives told us they made the decision because in some markets their
networks were significantly larger than their competitors, who already have
taken similar steps to reduce the size of their networks. They felt they needed
to “optimize” those networks to align with their competitors. A narrower
network, UHC's representatives said, will allow the company to invest more in
certain practices through incentive payment programs and also will eliminate
unwanted variations in care.

Regardless
of whether UHC's business decision was good for the insurer, it was poorly
timed, catching physicians and patients off guard during a critical time of
year. We stated again that decisions that affect such a significant number of
patients and physicians -- up to 18 percent of primary care physicians who
contract with UHC in some markets -- should be communicated to the Academy in
advance so we can alert our chapters and prepare our members.

According
to UHC, the company did not remove patients from coverage altogether. Instead,
it is working to move them to other practices in their network. As we told
them, however, cutting large numbers of physicians could create capacity and
access issues in some markets because many of our members do not have the
ability to significantly increase their patient panels.

Despite
the above matter, we were able to find common ground on some important issues.
For example, United agreed that we need a more continuous dialogue at the staff
level, and we identified a few issues that we will be actively engaged in with
UHC moving forward.

UHC
representatives also said they want to work with the Academy -- as well as
other payers -- to standardize and align quality measures, which would vastly
reduce the reporting burden physicians face. They also want to hear more about
the new evaluation and management codes for primary care physiciansthat the
Academy has recommended to CMS.

Care
management fees are another issue we will be discussing with UHC, which has
publicly stated that it plans to have at least 50 percent of its provider
network working under value-based contracts, rather than
strictly fee-for services arrangements, by 2015.

Fee
schedules that pay less than Medicare in some regions also were a topic of
discussion. We emphasized that other payers in these areas do pay above
Medicare rates, and to be viable, family medicine must be valued appropriately.

Working
with health plans can be challenging, but we can build on common issues that
keep the patient's best interest as our primary focus. We will stay engaged and
continue to promote the value of family medicine.

When Congress Is Ready to Listen, We're Ready to Talk

What a week this could have been.

I'm
making my first visit to Washington as the AAFP's President-elect, but the
agenda is a little thin. My schedule for Tuesday and Wednesday shows a trip to
the White House, meetings with legislators and staff from both houses of
Congress -- and both political parties -- as well as discussions with leaders
from three federal agencies.

Instead,
like most Americans, I'm waiting for federal employees to go back to work and
for members of Congress to stop pointing fingers and start solving problems. The
perpetual problem we had hoped to discuss with legislators -- one Congress
created -- is the sustainable growth rate (SGR) formula. For the first time,
Congress actually seemed to be taking clear steps toward replacing the flawed
Medicare formula before the government shutdown Oct. 1. In July, the House
Energy and Commerce Committee unanimously approved a Medicare physician payment
billthat would
abolish the SGR. The Senate Finance Committee is expected to release its own
version, or at least it was before things ground to a halt last week.

Without
congressional intervention, the SGR will trigger a nearly 25 percent reduction
in Medicare physician payments Jan. 1. Rest assured, we will reschedule our
meetings with legislators and continue our advocacy efforts as soon as Congress
stops is intransigence.

In
addition to our meetings with legislators, Academy leaders were scheduled to
meet this week with representatives from

the
Agency for Healthcare Research and Quality to discuss primary care research;

the
CMS Innovation Center to discuss studies related to the patient-centered
medical home model; and

the
Office of the National Coordinator for Health Information Technology to discuss
meaningful use regulations.

For
now, there are a more questions than answers. In the past few days, taking care
of a critically ill 2-year-old in my ER and seeing patients in my office has
made the problems in Washington seem secondary, at least for a few precious
moments. We are on the right path, creating access for our patients and
providing high quality primary care one patient at a time.

We
will get through this, and when Congress is ready to listen, we definitely will
be ready to talk.

The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.